Incidence and Trends of Pediatric Ovarian Torsion Hospitalizations in the United States, 2000 2006 Bridgette D.

Guthrie, Mark D. Adler and Elizabeth C. Powell Pediatrics 2010;125;532; originally published online February 1, 2010; DOI: 10.1542/peds.2009-1360

The online version of this article, along with updated information and services, is located on the World Wide Web at:
http://pediatrics.aappublications.org/content/125/3/532.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Incidence and Trends of Pediatric Ovarian Torsion Hospitalizations in the United States, 2000 2006
WHATS KNOWN ON THIS SUBJECT: Signicant variation exists in the management of pediatric ovarian torsion. An evolving body of literature indicates that attempts at ovarian salvage may be more successful than previously anticipated. National data regarding the demographics and management of ovarian torsion are lacking. WHAT THIS STUDY ADDS: We provide a robust national estimate of the incidence of pediatric ovarian torsionrelated hospitalizations and ovarian torsionrelated oophorectomy. Ovarian torsion is most commonly associated with normal ovaries or benign lesions, and ovarian malignancy or thromboembolic events occur rarely.
AUTHORS: Bridgette D. Guthrie, MD, Mark D. Adler, MD, and Elizabeth C. Powell, MD, MPH
Division of Pediatric Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois KEY WORDS ovarian torsion, abdominal pain, oophorectomy ABBREVIATIONS HCUPHealthcare Cost and Utilization Project KIDKids Inpatient Database CI condence interval ICD-9-CMInternational Classication of Diseases, Ninth Revision, Clinical Modication www.pediatrics.org/cgi/doi/10.1542/peds.2009-1360 doi:10.1542/peds.2009-1360 Accepted for publication Sep 3, 2009 Address correspondence to Bridgette D. Guthrie, MD, Childrens Memorial Hospital, Division of Pediatric Emergency Medicine, 2300 Childrens Plaza, Box 62, Chicago, IL 60614. E-mail: b-guthrie@md.northwestern.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright 2010 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to this article to disclose.

abstract
OBJECTIVE: There is signicant variation in the literature regarding the characteristics that are associated with pediatric ovarian torsion and its management. National data regarding the demographics and management of pediatric ovarian torsion are lacking. Our objective was to describe the epidemiology of pediatric ovarian torsion and the rate of oophorectomy by using nationally representative data. Demographic factors and hospital characteristics that are associated with rates of oophorectomy were also explored. METHODS: This was a cohort analysis of the Healthcare Cost and Utilization Project Kids Inpatient Database (KID) 2000, 2003, and 2006. All females aged 1 to 20 years who were hospitalized with ovarian torsion in states participating in KID 2000, KID 2003, and KID 2006 representing 900, 1224, and 1232 ovarian torsion-related hospitalizations, respectively, were included. Primary outcome measures included the incidence of ovarian torsion and rate of associated oophorectomy. Multivariable regression was used to control for patient and hospital characteristics. RESULTS: Among females aged 1 to 20 years, there were 1232 cases of ovarian torsion in KID 2006, an estimated incidence of 4.9 per 100 000. A total of 713 (58%) were treated with oophorectomy. The rate of ovarian torsionassociated oophorectomy remained unchanged from 2000 to 2006. The adjusted odds of having an oophorectomy decreased by 0.95 for every increasing year of age. Residing in a lower quartile of household income by zip code increased the adjusted odds of oophorectomy. A diagnosis of benign neoplasm increased the adjusted odds of oophorectomy by 2.16. Fewer than 0.5% of ovarian torsion hospitalizations were associated with malignant neoplasm. CONCLUSIONS: Nationally representative hospital data indicate that ovarian torsion is uncommon but occurs in all ages and is typically associated with normal ovaries or benign lesions. Improved awareness of the epidemiology may help to guide management. Ongoing analysis to identify factors that are associated with successful conservative management is warranted. Pediatrics 2010;125:532538

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Ovarian torsion is the twisting of the ovary on its vascular support. When ovarian torsion remains undiagnosed, blood supply becomes compromised, resulting in tissue necrosis and loss of function. Management includes detorsion or removal of the affected ovary.15 An evolving body of literature indicates that ovarian salvage, accomplished by detorsion of the affected ovary without removal, may be more successful than previously anticipated in children.4,5 Case reports and case series data describe the demographics and management of pediatric ovarian torsion at individual institutions; however, nationally representative data are lacking. Adult data suggest that ovarian torsion accounts for 3% of acute abdominal pain in females.6 Attempts at ovarian salvage were rst reported in adult women. Published literature on this topic reports a success rate of 90%, as dened by follicular development or normal macroscopic appearance of the ovary at follow-up, despite a necrotic appearance at the time of detorsion.79 Ovarian torsion is frequently associated with ovarian pathology in adults; however, the presence of ovarian lesions may be less common in children.1,10 Hospital characteristics and individual patient factors have been associated with management variations in other pediatric surgical conditions, including testicular torsion, appendicitis, and traumatic splenic injuries.1113 The objectives of this study were to describe the epidemiology of ovarian torsion and the rate of oophorectomy by using a large inpatient database. We also explored demographic factors and hospital characteristics that are associated with variation in rates of ovarian torsionrelated oophorectomy.
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METHODS
Data Source and Study Population The Healthcare Cost and Utilization Project (HCUP), sponsored by the Agency for Healthcare Research and Quality, is a family of health care databases including the State Inpatient Database, Nationwide Inpatient Sample, and Kids Inpatient Database (KID) and is the largest collection of multiyear, all-payer, encounter-level, health care data available in the United States. This study was a retrospective cohort analysis of the HCUP KID 2000, 2003, and 2006.1416 The KID, available every 3 years since 1997, was specically designed to report hospital use and outcomes for children and is the only all-payer inpatient care database for children in the United States. The KID is a stratied sample of all pediatric discharges, dened as age 20 years, from states that participate in HCUP. States that participate in HCUP provide dischargelevel data on all inpatient discharges from all community hospitals (ie, nonfederal, short-term, general, and specialty hospitals) in that state. Pediatric discharges from these states are stratied by HCUP to produce a 10% stratied sample of uncomplicated inhospital births and 80% stratied sample of other pediatric cases. The KID 2000 included 2784 hospitals in 27 states, KID 2003 included 3438 hospitals in 36 states, and KID 2006 included 3739 hospitals in 38 states. The KID has developed discharge weights for use in generating national estimates, with condence intervals (CIs), of total US discharges for specic diagnoses and procedures. These weights are adjusted to produce rates that are comparable across years despite variation in the number of participating states. Pediatric hospitalizations for patients who were aged 20 years and had an

International Classication of Diseases, Ninth Revision, Clinical Modication (ICD-9-CM) code for torsion of the ovary, ovarian pedicle, or fallopian tube (620.5) listed as a diagnosis on the discharge record were selected for our analysis.17 Ovarian torsion hospitalizations with ICD-9-CM procedure codes for laparoscopic unilateral oophorectomy (65.31), other unilateral oophorectomy (65.39), unilateral laparoscopic salpingo-oophorectomy (65.41), or other unilateral salpingooophorectomy (65.49) were dened as undergoing oophorectomy. We describe ovarian pathology (cysts, benign or malignant neoplasm) by using reported ICD-9-CM codes (follicular cyst of ovary: 620.0; corpus luteum cyst: 620.1; unspecied ovarian cyst: 620.2; benign neoplasm of ovary: 220; malignant neoplasm of ovary: 183). Cases with 1 code for ovarian pathology were included in the analysis of each condition. Patients who were hospitalized with a diagnosis of ovarian torsion that was not associated with a code for oophorectomy were considered to have undergone ovarian salvage. Because of the reported association between pulmonary thromboembolism and ovarian detorsion, we reviewed ICD-9-CM diagnosis codes (415.1) for this complication.18 Age-specic census estimates of the US female population were used to compute rates of ovarian torsion per 100 000 females. The US female population aged 1 to 20 years on July 1 for the years 2000, 2003, and 2006 was extrapolated from census estimates produced by the Population Estimates Program of the US Census Bureau. The institutional review board of our institution approved this study. Statistical Analysis Analyses were conducted to determine the effect of various patient-specic and hospital-specic variables on
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the risk for oophorectomy. Patientspecic variables included age, race, admission source (emergency department, other), insurance status (private, Medicaid, self-pay, other), median household income by zip code quartiles (for KID 2006: $0 $37 999, $38 000 $46 999, $47 000 $61 999, and $62 000), days to primary procedure, and length of hospital stay. Hospital characteristics included hospital type (general, childrens), teaching institution (yes, no), hospital location (urban, rural), and hospital region (Northeast, Midwest, South, West). Some variables had missing information because of data restriction use or incompleteness of records. Race/ethnicity was unavailable for 28% of ovarian torsion hospitalizations within KID 2006, consistent with missing race information within the entire KID 2006 data set. Because of the large amount of missing race data, race was analyzed in 3 ways: with the missing variables removed from the analysis, assigned as a separate covariate category, or assigned to the majority covariate level (white race). Other variables with missing information for at least 1% of ovarian torsion hospitalizations in KID 2006 include time to primary procedure (16%) general/childrens hospital (5%), hospital teaching status (2%), urban/rural location (2%) and median household income by zip code (2%). Statistical analyses were performed by using Stata 10.1 (Stata Corp., College Station, TX). National estimates and 95% CIs were calculated by using discharge-level statistical weights provided by KID for this purpose. Bivariate analyses were conducted on the statistically unweighted sample by using 2 test for categorical variables. Stata survey commands were used to compute variances for national estimates to account for hospital clustering and stratication. Logistic regression by
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TABLE 1 Ovarian Torsion Cases, Weighted Estimate, and Oophorectomy Rate for Each Year of the
KID
Year Casesa National Estimate, OR (95% CI) 1704 (15601848) 2035 (18822189) 1965 (18142117) Oophorectomy, n (%) 546 (61) 749 (61) 713 (58) National Estimate, (95% CI) 999 (8941104) 1207 (11091305) 1133 (10361229)

2000 2003 2006

a

900 1224 1232

Age 1 year.

FIGURE 1
Number of females by age in years with ovarian torsion, KID 2006.

using weighted data was used to identify signicant associations between patient or hospital factors and the occurrence of oophorectomy.

RESULTS
Overall Ovarian torsion cases, weighted national estimates, and rate of oophorectomy in KID 2000, KID 2003, and KID 2006 are presented in Table 1. The KID 2003 and KID 2006 had a larger sampling frame than did KID 2000 (3438 and 3739 vs 2784 hospitals, respectively). We report the estimated national incidence of ovarian torsion and oophorectomy rates for 2000, 2003, and 2006 in Table 1; all other detailed analyses that we report were conducted by using only the KID 2006. In the KID 2006, a total of 1232 hospitalizations were associated with ovarian torsion among females aged 1 to 20 years. The number of ovarian torsion

cases nationally, estimated by using a weighted analysis of the data, was 1965 cases (95% CI: 1814 2117). The estimated incidence of ovarian torsion was 4.9 per 100 000 females aged 1 to 20 years. Of the 1232 identied cases, 713 (58%) had an oophorectomy. The oophorectomy rate was similar in KID 2000 and 2003 (Table 1). There were no mortalities. Patient and Hospital Characteristics Age distribution is presented in Fig 1. The mean age was 14.5 years (SD: 3.9). Table 2 shows patient characteristics that were associated with ovarian torsion. Of the 72% with race information available, 51% were white. Race was not associated with oophorectomy in any model and was not included in the multivariate analysis. Most patients were admitted through the emergency department (63%) and

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TABLE 2 Patient Characteristics Associated

With Ovarian Torsion in KID 2006
Variable Age 15 610 1115 1620 Race White Black Hispanic Otherb Not specied Primary expected payer Private Medicaid Self-pay Otherc Not specied Admission source ED Otherd Not specied Median income by zip code $1$37 999 $38 000$46 999 $47 000$61 999 $62 000 Not specied n 30 131 510 561 455 118 249 78 332 704 373 96 59 0 775 457 0 315 271 312 310 24 %
a

TABLE 3 Hospital Characteristics Associated

With Ovarian Torsion in KID 2006
Variable Hospital type General Childrens hospital/unit Not specied Hospital teaching status Teaching Nonteaching Not specied Hospital location Urban Rural Not specied Region Northeast Midwest South West
a

TABLE 4 Comparison of Ovarian Torsion

a

n 758 411 63 743 467 22 1132 78 22 214 271 414 333

Having Versus Not Having an Oophorectomy in KID 2006

Variable Oophorectomy No (n 713), Oophorectomy n (%) (n 519), n (%) 23 (3) 89 (13) 277 (39) 324 (45) 268 (51) 79 (15) 134 (25) 45 (9) 7 (1) 42 (8) 233 (45) 237 (46) 187 (50) 39 (10) 115 (31) 33 (9)

2 11 41 46 51 13 28 8

65 35 Age, ya 15 610 1115 1620 Race White Black Hispanic Otherb Primary expected payer Private Medicaid Self-pay Otherc Admission source ED Otherd Median income by zip codea $1$37 999 $38 000$46 999 $47 000$61 999 $62 000 Hospital type General Childrens hospital/unit Hospital teaching status Teaching Nonteaching Hospital location Urban Rural Hospital regiona Northeast Midwest South West

61 39

94 6

57 30 8 5

17 22 34 27

Of nonmissing totals.

63 37

402 (56) 226 (32) 54 (8) 31 (4) 430 (60) 283 (40)

302 (58) 147 (28) 42 (8) 28 (6) 345 (66) 174 (44)

26 22 26 26

length of hospitalization, 2.6 days (95% CI: 2.52.7), was approximately onehalf day longer in the oophorectomy group, 2.3 (95% CI: 2.0 2.6) vs 2.8 days (95% CI: 2.73.0). Table 4 presents the relative frequency of patient and hospital characteristics and their relationship with oophorectomy. Stratied analysis of age groups demonstrated that the oophorectomy rate decreased with increasing age: among females aged 1 to 5 years: 77%; in those aged 6 to 10 years: 68%; in those aged 11 to 15 years: 54%; and in those aged 16 to 20 years: 58% (2, P .05). Using an age of 12 years, the average age for menarche in the United States, to compare management of prepubertal with postpubertal females, those who were younger than 12 years were more likely to undergo oophorectomy than those who were aged 12 years (66% vs 56%; P .05). Females who resided in zip codes with lower median incomes were also more likely to undergo oophorectomy. Females in the lowest median income by zip code quartile ($37 999) had an oophorectomy rate higher than those in the highest quartile ($62 000; 67% vs 53%; P .05). This association remained when median household in-

ED, indicates emergency department. a Of nonmissing totals. b Includes Asian/Pacic Islander, Native American, and other. c Includes Medicare, no charge, and other. d Includes routine admissions and transfers from other hospitals/facilities.

211 (30) 158 (22) 166 (24) 165 (24) 447 (66) 229 (34)

104 (20) 113 (22) 146 (29) 145 (29) 311 (63) 182 (37)

had private health insurance (57%). Hospital characteristics are presented in Table 3. Most ovarian torsion hospitalizations were in general hospitals, hospitals designated as teaching, and those located in an urban location. The day of primary procedure was available for 1036 (84%) cases. Of the 693 who had their primary procedure performed on the day of admission, 400 (58%) had an oophorectomy. Of the 251 who underwent their primary procedure on the day after admission, 152 (61%) had an oophorectomy. Day of primary procedure was missing for 100 females who had an oophorectomy and 96 females who did not, resulting in a greater proportion of missing data for those who did not have an oophorectomy (19% vs 13%). The average
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439 (61) 279 (39) 650 (93) 52 (7) 108 (15) 167 (23) 256 (36) 182 (26)

320 (63) 188 (37) 482 (95) 26 (5) 106 (20) 104 (20) 158 (31) 151 (29)

ED, indicates emergency department. a 2, P .02. b Includes Asian/Pacic Islander, Native American, and other. c Includes Medicare, no charge, and other. d Includes routine admissions and transfers from other hospitals/facilities.

come by zip code was compared between those above the midpoint of zip code grouping (zip codes with a median income of $47 000) and those below the midpoint ($47 000; 63% vs 53%; P .05). We did not observe a difference in proportion of patients
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who underwent oophorectomy on the basis of race, primary expected payer, admission source, hospital type, hospital teaching status, or hospital location. Ovarian pathology associated with ovarian torsion is presented as unweighted data in Table 5. Malignant neoplasm of the ovary was rare (5 of 1232), 0.5% of all cases of torsion. A higher proportion of females with a codiagnosis of benign ovarian neoplasm underwent oophorectomy than those without a co-diagnosis (71% vs 53%; P .05). There was no difference in oophorectomy rates for those with a co-diagnosis of ovarian cyst (55% vs 59%; P .05). Twenty-seven females had a diagnosis of both benign neoplasm and ovarian cyst; 9 had conservative treatment and 18 had an oophorectomy. All 5 females with a co-diagnosis of malignant ovarian neoplasm underwent oophorectomy. No diagnoses of pulmonary thromboembolism were associated with ovarian torsion hospitalizations. The reported multivariate analysis estimating the probability of oophorectomy included adjustment for age, primary expected payer, admission source, median income by zip code, hospital type, hospital teaching status, hospital location, hospital region, and associated diagnosis (Table 6). In the nal model, age, median household income by zip code, and presence of a benign neoplasm signicantly affected the likelihood of oophorectomy. For every 1-year increase in age, the adjusted odds of having an oophorec-

TABLE 6 Multivariate Predictors of

Oophorectomy for Females Aged 1 to 20 Years With Ovarian Torsion
Variable Age Primary expected payer Private Medicaid Self-pay Other Admission source ED Other Median income by zip $1$37 999 $38 000$46 999 $47 000$61 999 $62 000 Hospital type General Childrens Hospital teaching status Teaching Nonteaching Hospital location Urban Rural Hospital region Northeast Midwest South West Associated diagnosis None Benign neoplasm Ovarian cyst OR (95% CI) 0.95 (0.920.98) P .0070

DISCUSSION
Ovarian torsion is an uncommon condition in the pediatric population. The data that we reviewed, allowing us to make national estimates, indicate that ovarian torsion has an annual incidence of 4.9 per 100 000 females aged 1 to 20. Comparing this rate with other pediatric surgical conditions, ovarian torsion is much less common than appendicitis but is remarkably similar to the estimated incidence of testicular torsion, 4.5 per 100 000 males aged 1 to 25, which has an estimated orchiectomy rate of 35%.11,19 The estimated rate of oophorectomy in ovarian torsion was 60% and was stable across the years studied. Concern for malignancy associated with ovarian torsion and risk for thromboembolism have been cited as reasons favoring oophorectomy.18,20 In our analysis, ovarian torsion was infrequently associated with a diagnosis of malignant neoplasm, occurring in 5 of 1241 cases. No diagnosis of pulmonary thromboembolism was recorded in any ovarian torsionrelated hospitalization. Younger patient age, lower median household income by zip code, and presence of a benign neoplasm were associated with an increased rate of oophorectomy. In the United States, the average age of menarche is 12 years. A total of 208 (17%) females in our sample were younger than 12 years and dened as prepubertal. This is a smaller proportion than reported by other case series of girls and adolescents with ovarian torsion, in which the proportion of prepubertal girls accounted for 32% to 68% of cases.1,2123 These studies were conducted at tertiary care childrens hospitals, whose patient demographics were likely skewed toward younger aged patients. The data that we report are likely more representative of the age distribution of ovarian torsion. It is important to

Reference 1.04 (0.781.38) 1.09 (0.651.84) 0.86 (0.461.60) Reference 1.22 (0.921.61)

.7700 .7200 .6400

.1600

Reference 0.65 (0.450.93) 0.51 (0.360.72) 0.54 (0.380.77) Reference 1.25 (0.881.78)

.0190 .0001 .0010

.2000

Reference 0.91 (0.681.21) Reference 0.83 (0.471.45) Reference 1.48 (0.982.25) 1.25 (0.811.93) 1.05 (0.711.56) Reference 2.16 (1.543.03) 1.00 (0.751.32)

.5300

.5200

.0600 .3000 .7700

.0001 .9900

TABLE 5 Diagnoses Associated With Ovarian

Torsion in KID 2006
Diagnosis Ovarian cyst Benign neoplasm of ovary or adnexa Malignant neoplasm of ovary or adnexa
a

n 435 281 5

%a 35.0 23.0 0.4

Of total cases; sum does not equal 100%.

tomy decreased by 0.95 (95% CI: 0.92 0.98), or a 5% decrease in odds per year. Residing in a higher quartile of household income by zip code also decreased the adjusted odds of oophorectomy. Compared with those in the lowest quartile ($38 000), the next highest quartile ($38 000 $46 999) had an adjusted odds of having an oophorectomy of 0.65 (95% CI: 0.450.93), followed by an adjusted odds of 0.51 (95% CI: 0.36 0.72) for the third quartile ($47 000 $61 999) and 0.54 (95% CI: 0.38 0.77) for the top quartile ($62 000). A diagnosis of benign neoplasm increased the adjusted odds of having an oophorectomy by 2.16 (95% CI: 1.54 3.03).

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note that although we observed a higher incidence of ovarian torsion among girls after puberty, it occurs in younger girls and should be considered in the differential diagnosis of all females with abdominal pain. A high index of suspicion for ovarian torsion before operative intervention has been associated with an increase in the likelihood of ovarian salvage and may explain the lower rate of salvage in younger females.4 The reported association between median household income by zip code and oophorectomy warrants additional investigation. Although a lower median household income by zip code would seem to be an accurate indicator of low socioeconomic status, it is a proxy for self-reported household income data. Another possible marker of socioeconomic status, Medicaid as primary expected payer, was not associated with oophorectomy. In the KID, median income household income by zip code is based on the patients zip code and is grouped in quartiles, precluding a more detailed analysis of the relationship between income and oophorectomy. Ovarian torsion was associated with a benign mass lesion in 58% of hospitalizations. This is similar to previously reported rates between 50% and 85%.1,4,5,21,22 Females with ovarian torsion and a co-diagnosis of benign neoplasm were more likely to undergo oophorectomy, possibly because of concerns for malignancy at the time of macroscopic inspection. Given the low rates of malignant lesions in torsed ovaries, the data suggest that the presence of a mass lesion should not preclude attempted ovarian salvage. To maximize ovarian salvage, some physicians advocate for biopsy of lesions with a suspicious macroscopic appearance. These patients should then be followed with ultrasonography, second look procedures, or meaPEDIATRICS Volume 125, Number 3, March 2010

surement of tumor markers.24,25 Laparoscopic cystectomy with ovarian preservation has been successfully demonstrated in a pediatric population with benign ovarian tumors.26 Current literature indicates that the management of ovarian torsion may be evolving. The standard management for many years was removal of the torsed ovary. Delays in both presentation and diagnosis were thought to limit severely the likelihood of viability, resulting in removal1,3; however, the association between duration of symptoms and successful detorsion is not clear. Successful detorsion was rst reported in female adults.8,9 Case series data involving children are accumulating and suggest successful conservative management with detorsion despite a necrotic appearance.4,5,23 In a series of 35 children by Aziz et al,4 16 had detorsion attempted and all were successful. Of these 16 cases, 53% of the torsed ovaries were judged to be moderately or severely ischemic at the time of detorsion. Follow-up was available for 14 patients, and all had functional ovaries as determined by ultrasound and/or biopsy. Rousseau et al23 reported a series of 40 cases; detorsion was attempted in 19 of these cases, and all were successful. Celik et al5 reported the successful return of normal ovarian function in 13 of 14 patients who underwent detorsion despite a necrotic appearance at the time of macroscopic inspection. Although the relative benet of ovarian salvage remains unclear, possession of 2 functioning ovaries may extend the reproductive life span and maximize the fertility potential of young females.27 The data that we reviewed do not show a change over time in the oophorectomy rate in children with ovarian torsion. It is possible that the oophorectomy rate has changed and our analysis failed to capture it. The case

series data reporting successful detorsion in children were published between 2004 and 2008. Ongoing analyses are important to understanding this rate and factors that contribute to successful detorsion. There are methodologic limitations to our study. Physiologic and laboratory data are unavailable within the KID, thereby precluding analysis related to clinical presentation or diagnostic evaluation. We used the ICD-9-CM diagnostic codes for identication of ovarian torsion hospitalization and oophorectomy, and we cannot ascertain missing codes. Coding errors and hospital variation in coding could potentially affect results. We cannot exclude the potential for bias as a result of unobserved covariates. KID data are disclosed in limited data set form without unique patient identiers; therefore, repeat hospitalizations cannot be determined. The KID does not contain variables that identify physician specialty, and we are unable to comment on the relationship between provider type and management. The KID is limited to inpatient hospitalizations and may underestimate the incidence of torsion and misrepresent salvage rates if cases are managed primarily in outpatient settings. Finally, the time course from hospital admission to operative intervention is available only as a single interval, the day of hospitalization (ie, day of admission, day after admission), limiting more detailed analysis of this association.

CONCLUSIONS
To our knowledge, this is the largest analysis of pediatric ovarian torsion related hospitalizations in the United States. We provide a robust national estimate of the incidence of pediatric ovarian torsionrelated hospitalizations and ovarian torsionrelated oophorectomy. Ovarian torsion is most commonly associated with normal
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ovaries or benign lesions, and ovarian malignancy or thromboembolic events occur rarely. A growing body of literature supporting conservative manageREFERENCES
1. Kokoska E, Keller M, Weber T. Acute ovarian torsion in children. Am J Surg. 2000;180(6): 462 465 2. Meyer J, Harmon C, Harty M, Markowitz R, Hubbard A, Bellah R. Ovarian torsion: clinical and imaging presentation in children. J Pediatr Surg. 1995;30(10):14331436 3. Mordehai J, Mares A, Barki Y, Finaly R, Meizner I. Torsion of uterine adnexa in neonates and children: a report of 20 cases. J Pediatr Surg. 1991;26(10):11951199 4. Aziz D, Davis V, Allen L, Langer J. Ovarian torsion in children: is oophorectomy necessary? J Pediatr Surg. 2004;39(5):750 753 5. Celik A, Ergun O, Aldemir H, et al. Long-term results of conservative management of adnexal torsion in children. J Pediatr Surg. 2005;40(4):704 708 6. Hibbard L. Adnexal torsion. Am J Obstet Gynecol. 1985;152(4):456 461 7. Oelsner G, Cohen S, Soriano D, Admon D, Mashiach S, Carp H. Minimal surgery for the twisted ischaemic adnexa can preserve ovarian function. Hum Reprod. 2003;18(12): 2599 2602 8. Shalev E, Bustan M, Yarom I, Peleg D. Recovery of ovarian function after laparoscopic detorsion. Hum Reprod. 1995;10(11): 29652966 9. Shalev J, Goldenberg M, Oelsner G, et al. Treatment of ischemic twisted adnexa by simple detorsion. N Engl J Med. 1989;321(8): 546 10. Varras M, Tsikini A, Polyzos D, Samara C, Hadjopoulos G, Akrivis C. Uterine adnexal

ment of ovarian torsion may decrease over time the rate of torsion-related oophorectomy. Ongoing analysis will be important to determine changes in

the rate of ovarian torsionrelated oophorectomy and factors that are associated with successful conservative management.

11.

12.

13.

14.

15.

16.

17.

18.

torsion: pathologic and gray-scale ultrasonographic ndings. Clin Exp Obstet Gynecol. 2004;31(1):34 38 Mansbach J, Forbes P, Peters C. Testicular torsion and risk factors for orchiectomy. Arch Pediatr Adolesc Med. 2005;159(12): 11671171 Kokoska E, Bird T, Robbins J. Racial disparities in the management of pediatric appendicitis. J Surg Res. 2007;137(1):83 88 Bowman S, Zimmerman F, Christakis D, Sharar SR, Martin DP. Hospital characteristics associated with the management of pediatric splenic injuries. JAMA. 2005;294(20): 26112617 Healthcare and Cost Utilization Project. Kids Inpatient Database, 2000 [CD-ROM]. Rockville, MD: Agency for Healthcare Research and Quality; 2003 Healthcare and Cost Utilization Project. Kids Inpatient Database, 2003 [CD-ROM]. Rockville, MD: Agency for Healthcare Research and Quality; 2005 Healthcare and Cost Utilization Project. Kids Inpatient Database, 2006 [CD-ROM]. Rockville, MD: Agency for Healthcare Research and Quality; 2008 National Center for Health Statistics. Classication of diseases, functioning, and disability. Hyattsville, MD; 2006. Available at: www.cdc.gov/nchs/icd9.htm#RTF. Accessed December 1, 2008 McGovern P, Noah R, Koenigsberg R, Little A. Adnexal torsion and pulmonary embolism: case report and review of the literature. Obstet Gynecol Surv. 1999;54(9):601 608

19. Bratton S, Haberkern C, Waldhausen J. Acute appendicitis risks of complications: age and Medicaid insurance. Pediatrics. 2000;106(1 pt 1):7578 20. Sommerville M, Grimes D, Koonings P, Campbell K. Ovarian neoplasms and the risk of adnexal torsion. Am J Obstet Gynecol. 1991; 164(2):577578 21. Rousseau V, Massicot R, Ahmed A, et al. Emergency management and conservative surgery of ovarian torsion in children: a report of 40 cases. J Pediatr Adolesc Gynecol. 2008;21(4):201206 22. Anders J, Powell E. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med. 2005;159(6):532535 23. Chang Y, Yan D, Kong M, et al. Adnexal torsion in children. Pediatr Emerg Care. 2008; 24(8):534 537 24. Oelsner G, Bider D, Goldenberg M, Admon D, Mashiach S. Long-term follow-up of the twisted ischemic adnexa managed by torsion. Fertil Steril. 1993;60(6):976 979 25. Dolgin S, Lublin M, Shlasko E. Maximizing ovarian salvage when treating idiopathic adnexal torsion. J Pediatr Surg. 2000;35(4): 624 626 26. Karpelowsky J, Hei E, Matthews K. Laparoscopic resection of benign ovarian tumours in children with gonadal preservation. Pediatr Surg Int. 2009;25(3):251254 27. Lass A. The fertility potential of women with a single ovary. Hum Reprod Update. 1999; 5(5):546 550

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GUTHRIE et al

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Incidence and Trends of Pediatric Ovarian Torsion Hospitalizations in the United States, 2000 2006 Bridgette D. Guthrie, Mark D. Adler and Elizabeth C. Powell Pediatrics 2010;125;532; originally published online February 1, 2010; DOI: 10.1542/peds.2009-1360
Updated Information & Services References including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/125/3/532.full.ht ml This article cites 23 articles, 4 of which can be accessed free at: http://pediatrics.aappublications.org/content/125/3/532.full.ht ml#ref-list-1 This article has been cited by 2 HighWire-hosted articles: http://pediatrics.aappublications.org/content/125/3/532.full.ht ml#related-urls Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://pediatrics.aappublications.org/site/misc/Permissions.xht ml Information about ordering reprints can be found online: http://pediatrics.aappublications.org/site/misc/reprints.xhtml

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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